Advances in Psychiatric Treatment (2998), vol. 4, pp.

159-166

Psychiatric aspects of diabetes mellitus

Peter Trigwell & Robert Peveler

In 1899, Maudsley wrote: untreated. Diabetes is either primary (idiopathic)

"Diabetes is a disease which often shows itself in
families in which insanity prevails: whether one disease
predisposes in any way to the other or not, or whether
they are independent outcomes of a common neurosis,
they are certainly found to run side by side, or
alternately with one another more often than can be
accounted for by accidental coincidence or sequence".
Recent research confirms that a range of psycho
logical problems and psychiatric disorders are
common in people with diabetes. Such problems
are important not only because of the suffering
caused, but also because of their impact upon the
management and outcome of the diabetes itself.
This article reviews the psychosocial impact of
diabetes and its treatment, describes the range of
psychological problems and psychiatric disorders
which commonly occur in people with diabetes,
and outlines the role of the psychiatrist in the
recognition and management of these clinical
problems.
or secondary (with various possible causes,
including pancreatic destruction by malignant
tumour or pancreatitis, and insulin antagonism by
steroid therapy). There are two principal forms of
the disease.
Type I diabetes
Often called insulin-dependent diabetes mellitus,
this type usually develops during childhood or
adolescence, presenting acutely with severe
symptoms of malaise, fatigue, weight loss, polyuria,
polydipsia, infections and sometimes coma.
Type II diabetes
Often called non-insulin dependent diabetes
mellitus, this tends to occur in the overweight and
the elderly. It is often asymptomatic and detected
by routine urine testing, but sufferers may present
with infection or vascular complications.

Medical complications
Diabetes mellitus
Clinicalfeatures
Diabetes mellitus is a common, chronic condition
caused by diminished availability or effectiveness
of endogenous insulin. About 19t of the population
of the UK are recognised to be suffering from
diabetes, but most authorities estimate that another
1% have the condition, but go undiagnosed or
Diabetes (particularly Type I) is accompanied by
long-term microvascular, neurological and macro-
vascular complications. These include retinopathy,
nephropathy, neuropathy, cardiovascular disease
and peripheral vascular insufficiency. They are a
major cause of morbidity and mortality, but research
has confirmed that good glycaemic control sig
nificantly reduces the risk of eventual medical
complications (Diabetes Control and Complications
Research Group, 1993).

Peter Trigwell qualified and trained in psychiatry in Leeds. His main research interest is in psychological factors which affect the presentation,
management and outcome of physical illness. Part of his clinical work involves psychiatric input to the diabetes service of a large teaching
hospital (The General Infirmary at Leeds, Great George Street, Leeds LSI 3EX).Robert Peveler qualified and trained in psychiatry in Oxford.
His research interests include treatment adherence and medically unexplained physical symptoms. His clinical interests are in consultation-
liaison psychiatry and general practice psychiatry.
 APT(1998),vol.4,p.l60
Physical management
Of all chronic disorders, diabetes arguably requires
the greatest level of active involvement in manage
ment and self-care. In addition to the multi-
disciplinary services that he or she might receive, a
person with diabetes must, in many ways, be their
own doctor, nurse, dietician and biochemist
(paraphrasing R. D. Lawrence, founder of the
British Diabetic Association). In broad terms,
management of diabetes consists of balancing
events which raise blood glucose (e.g.. consuming
foodstuffs which contain carbohydrate) with events
which lower blood glucose (e.g. exercise, insulin
or oral hypoglycaemic medication). The aim is to
keep the blood glucose within the normal range as
far as possible, and hence to avoid later medical
complications. A high blood glucose level may lead
to symptoms of hyperglycaemic ketoacidosis
(similar to the presenting symptoms of Type I
diabetes as listed above). A low blood glucose level
causes hypoglycaemia, leading to hunger, sweating,
agitation and confusion. Coma may follow,with the
possibility of irreversible brain damage. The day-
to-day management ofdiabetes is described in Box1.
Coping with diabetes
In view of the importance of self-care, the way in
which people adjust to having diabetes is crucial to
Box 1. Components of successful day-to-day
management of diabetes
Diet- increased intake of fibre and complex
carbohydrates and reduced fat intake are
encouraged
Medication-oral hypoglycaemic medication
may be necessary in Type II diabetes in
addition to dietary management; regular
subcutaneous injections of exogenous
insulin are also required in Type I diabetes
(and sometimes in Type II)
Exercise - aerobic exercise is valuable for
weight loss, decreasing insulin resistance
in Type II diabetes and reducing the risk
of hypertension and cardiovascular disease
Monitoring - blood and/or urine glucose
levels are monitored to allow immediate
decisions concerning other aspects of
management
Trigwell & Peveler
the outcome. It determines the risk both of serious
medical complications and of psychological
problems or psychiatric disorder. The onset of
diabetes, especially Type I, brings many pressures
and difficulties. Following diagnosis there will
often be a 'honeymoon period' lasting for a few
weeks or months. During this time the person may
appear to be adapting well to the demands and
restrictions of the treatment regime. There may be
an element of novelty, so that monitoring and
administration of medication is interesting and not
too onerous. Eventually, a proportion will begin to
cope less well. They may pass through stages
similar to those seen in a bereavement reaction:
disbelief, denial, anger and depression. The
similarity with grief is probably because the
diagnosis of diabetes threatens various losses: of
job or career potential, of sexual function and
reproductive potential, of eyesight or limbs, or of a
sense of control over one's life and future.
Psychological hurdles
Diabetes, in common with any chronic physical
illness, poses numerous psychological hurdles
(Maguire & Haddad, 1996).
Uncertainty about the future
The range of possible long-term outcomes in
diabetes is very wide, from no significant medical
complications to blindness, amputation, renal
failure or severe neuropathic pain. Examples of
poor outcomes are repeatedly encountered in the
diabetes clinic, and uncertainty about outcome is
likely to be a particular problem for those who have
had adverse experiences of diabetes in friends or
relatives. These concerns must be actively and
empathically addressed in order to avoid unneces
sary distress; the treatment and outcome of diabetes
have improved a great deal since older relatives
were diagnosed.
Loss of control
Some perceive diabetes to have 'taken over' their
life, leading either to a feeling of helplessness or an
angry, rebellious response.
Being secretive
As a result of concern over the acceptability of their
diagnosis to others, particularly employers or
insurers, some people may keep it a secret. In
view of the possibility of hypoglycaemic episodes,
and other potential problems, this can be very
dangerous.
 Psychiatrie aspects of diabetes
Coping styles and strategies
Three factors are particularly important in
determining how an individual reacts to the
diagnosis.
Individual perceptions
The extent of social disability varies according to
how serious the person perceives their condition
to be, rather than according to the degree of
seriousness perceived by doctors. Because of this,
it is particularly important to find out what the
person's understanding and expectations are.
Personality traits and previous ways of coping
Those with marked dependent, avoidant or
obsessional traits are likely to adapt less well.
Coping style
Denial has been found to be an adaptive and useful
coping style in some physical disorders (Gréeret
al, 1979). In diabetes, however, it is a common but
maladaptive reaction to the diagnosis. Some people
may behave as if they do not actually have diabetes
at all, and there may be an element of 'magical'
thinking ('if I ignore this, and behave as if it doesn't
exist, it will go away/I won't have it at all'). In some
cases the result of this will be emergency admission
due to severe hyperglycaemia. The overall coping
strategy depends upon the balance between
how much lifestyle is modified to accommodate
diabetes, and how much the regime is made to fit
around other activities with the minimum possible
impact.
Adherence or self-care
Adherence can be defined as the extent to which a
person's behaviour (medication-taking, diet, or
lifestyle change) coincides with medical or health
advice (Haynes et al, 1979). There is a tendency to
consider problems with coping as synonymous
with non-adherence. However, this is an over-
simplistic and unhelpful approach which assumes
that one specific treatment plan exists which is
effective in all situations. In fact, people must
modify their regime in accordance with blood and
urine test results, activity levels, infections and
other illness episodes. In short, there is no clearly
defined treatment for them to adhere to. A more
useful term to describe this is self-care. There are
many reasons why behaviour may deviate from the
usual regime. When problems with glycaemic
control arise it is important to look for any
APT (1998),vol. 4, p. 161
mismatch between the regime and the preferred
lifestyle. Recent research has examined the
importance of motivation in diabetes, and it may
prove possible to improve poor glycaemic control
using a motivational interviewing approach
(Trigwelleffl/, 1997).
Presentation of psychological
problems
People with diabetes may complain directly of
psychological problems, but difficulties often
present initially as a change in behaviour. For
example, checking of blood glucose level may be
reduced in frequency or cease completely, insulin
injections may be missed, and good dietary habits
abandoned. Risk-taking behaviour such as smoking
or misusing alcohol or other drugs may begin or
increase. In dealing with this situation there are
several important points to remember (Box 2; see
Peveler & Tooke, 1995).
Ability to cope with diabetes can be increased by
a sympathetic and understanding approach,
offering advice and effective education. Some
people with diabetes and their families find the
series of "Coping with..." booklets published by the
British Diabetic Association very helpful. When
problems with glycaemic control arise, however,
they are usually not simply the result of educational
deficits; evaluation of education as a means of
improving inadequate self-care shows that it is
largely ineffective. Diabetes nurse specialists are
well placed to offer help, and tend to see the
majority of those with poor coping and psycho
logical problems. It is important, however, to
recognise that they are carrying out this work and
to provide suitable supervision and psychiatric
back-up in order to facilitate it.
Box 2. Points to remember when considering
a change in self-care behaviour of people
with diabetes
Self-care behaviour may be used to express
feelings that have nothing to do with the
diabetes itself.
Poor glycaemic control should be approached
as a problem of multi-factorial aetiology.
The person with diabetes must be managed
in a sensitive way, using a combined
approach by both medical and psychiatric
teams.
 APT(1998),vol.4,p.ì62
Entile diabetes
An extreme example of maladaptation to diabetes
is 'brittle diabetes'. This is characterised by gross
fluctuations in glycaemic control, often with
repeated emergency admissions. It is now widely
accepted that brittle diabetes is a behavioural rather
than a pathophysiological problem (Williams et al,
1991). In an influential paper in this area, Tattersall
& Walford (1985) concluded that:
"...such patients are neither 'mad' nor 'bad' but
indulge in potentially dangerous behaviour, partly
because they are ignorant of its consequences but more
often because it 'pays' in the sense of fulfilling other
needs, whether for love, shelter, approval or escape
from an otherwise insoluble conflict."
Sensitivity and tact are essential to engage the
person (who may be very reluctant or even hostile)
in psychological work, and blunt confrontation
should be avoided. Assessment should identify and
address important psychosocial factors. A link is
then made between periods of worse glycaemic
control and emotional distress or social difficulties.
A firm and consistent approach is essential,
requiring close liaison between psychiatric and
medical teams. A period of in-patient management
on a medical ward may be needed, with a senior
physician taking the lead role in dealing with the
person and coordinating the team approach.
Confrontation is not necessarily helpful: the mark
of success in these difficult cases is containment
and stabilisation of the situation, with eventual
improvement in the underlying problems,
improved glycaemic control, and, hopefully,
reduced need for admission.
Psychiatric disorder in diabetes
Difficulties in coping with diabetes may contribute
to the causation of psychiatric disorder, but often
such disorders have the same range of causes as
those seen in non-diabetic people; genetic risks, life
events unrelated to disease, and chronic social
difficulties. Psychological difficulties exist on a
continuum from mild to severe, and the 'cut-off
point for psychiatric disorder is arbitrary. What may
be considered a mild disorder in an otherwise well
person may assume greater clinical significance
when it occurs in conjunction with a chronic
physical disease, in view of its effects upon
behavioural management and physical outcome.
Rates of psychiatric disorder diagnosed according
to standardised criteria are higher in diabetes than
those expected in the general population (see Table
1), although it appears that the suicide rate is not
elevated overall (Harris & Barraclough, 1994). It is
Trigwell & Peveler
Table 1. Increased prevalence of psychiatric
diabetesStudy disorder in
Prevalence (%)
FemaleWilkinson
Male
18 24 hospital
t'fn/,1988 sample
Mayou 12 19 Young patients with
et al, 1991 diabetes mellitus
Rodgers & 3.8 8.6 General population
Mann, 1986SampleIDDM
Overall
Weyerer
ctn'l, 1989 43.1 Patients with
diabetes
26.2 Healthy control
subjects
IDDM, insulin-dependent (Type I) diabetes mellitus
notable that specific subgroups suffer particularly
high rates of psychiatric disorder: those with
medical complications, frequent admissions for
stabilisation, or brittle diabetes (Tattersall, 1985;
Wulsin et al, 1987; Wrigley & Mayou, 1991).
Depressive disorders
Depressive illness, with or without anxiety, is the
most common psychiatric disorder seen in people
with diabetes. Some studies suggest that depression
and/or anxiety may affect up to 50% of young
people with poorly controlled Type 1 diabetes (Orr
et al, 1983; Tattersall & Walford, 1985). The preva
lence of depression is significantly higher than
in the general population, and at the high end of
the continuum of depression prevalence in the
physically ill (Fris & Nunjandapper, 1986; Mayou
et al, 1991; Lustman et al, 1992). It is presumed that
at least part of this increased risk is due to
the psychosocial difficulties which accompany
diabetes, although it has been suggested that organic
factors may also be important (Geringer, 1990).
Treatment of depression in diabetes
For mild depressive syndromes the initial treatment
is to offer advice, information, explanation and
practical support to people with diabetes and their
families (Popkin et al, 1985). For more persistent
cases, specific psychological treatment such as
problem-solving therapy, cognitive-behavioural
therapy or interpersonal psychotherapy may be
used (although the lack of published studies of
psychotherapy for depression in diabetes mean that
 Psychiatrie aspects of diabetes
this approach lacks an evidence base). It is impor
tant to note that the presence of the symptoms and
signs of a major depressive disorder have exactly
the same significance in a person with diabetes as
they would in a person who is physically well.
Thus, the characteristics of a depressive disorder
that suggest a probable response to treatment in the
physically well also apply in those who have
diabetes. It is a common error to assume that the
depression is 'understandable under the circum
stances' and not to attempt to treat it. Depression
in people with diabetes has been demonstrated to
respond to antidepressant medication and to
electroconvulsive therapy (Kaplan et al, 1960; Fakhri
et al, 1980; Turkington, 1980; Finestone & Weiner,
1984).
Other benefits of antidepressants in diabetes
Tricyclic antidepressants such as amitriptyline and
imipramine (as well as low-dose phenothiazines
and carbamazepine) may be helpful in the treatment
of painful diabetic neuropathy. It has also been
suggested that antidepressant treatments including
imipramine, lithium, fluoxetine and electro-
convulsive therapy may reduce hyperglycaemia
and have 'antidiabetic effects', possibly by
increasing insulin sensitivity, although further
research is needed (Sarán,1982; Normand & Jenike,
1984; Trueeffl/, 1987).
Cautions
Selective serotonin reuptake inhibitors (SSRIs)
should be used with caution as they have been
reported to cause hypoglycaemic episodes (mainly
in non-insulin-dependent (Type II) diabetes
mellitus) and their side-effects (tremor, nausea,
sweating and anxiety) can be mistaken for hypo-
glycaemia (Bazire, 1996). There is also a need for
caution with tricyclic drugs, as their side-effects
(urinary bladder dysfunction, sedation, cardio-
toxicity, weight gain and adverse affects on sexual
function) can be troublesome. Particular care must
be taken if using antidepressants in people with
renal dysfunction.
Eating disorders
As with other disorders, there is a spectrum of
disturbance of eating habits and attitudes in people
with diabetes. Physicians long suspected that there
was an increased incidence of eating disorder in
people with diabetes, although studies of 'full
blown' anorexia nervosa or bulimia nervosa,
diagnosed according to standard criteria, suggest
that rates are not raised greatly, if at all (Fairburnef
APT (1998),vol. 4, p. 163
al, 1991; Peveler et al, 1992). Nevertheless, because
such disorders are common in the general popu
lation, particularly among teenage and young adult
women, and because sub-threshold cases or 'partial
syndromes' may also be clinically significant when
occurring in people with diabetes, they constitute
an important clinical problem.
The clinical features of people with both an eating
disorder and diabetes differ little from those of non-
diabetic patients. The principal difference is that
people with diabetes have available to them an
additional means of weight control: the under-use
or omission of insulin. Such self-induced glycosuria
is not restricted to people with eating disorders,
being common in younger women seeking to loose
weight. Eating disorder sufferers appear to have a
poor physical prognosis, with a high risk of physical
complications of diabetes (Steel et al, 1987), although
systematic studies are still required.
Satisfactory management depends upon success
ful detection of the condition. Sufferers are often
ashamed of or secretive about their behaviour, and
do not volunteer information about it in the clinic.
Poor glycaemic control, repeated episodes of
ketoacidosis or hypoglycaemia and weight fluctu
ations are important clues to diagnosis. Sensitive
but direct questions about eating habits and
attitudes need to be asked whenever the index of
suspicion is raised, and opportunities offered for
interviews in more confidential surroundings than
an open ward or a busy clinic.
Specific psychological treatments (cognitive-
behavioural therapy and interpersonal psycho
therapy) have been shown to be of benefit in non-
diabetic patients, and can be translated to the
treatment of people with diabetes, although
management is more complex (Peveler & Fairburn,
1992). A major difficulty is that psychological
treatment services are not well equipped to deal
with such a combination of problems, and dedicated
liaison psychiatry services are probably best placed
to do this work, where they exist.
Unfortunately, no research evidence exists to
guide the management of the large number of
people with dietary problems falling short of full
eating disorder. Dietary advice is usually given by
the dietician or specialist nurse, but clinical
experience indicates that this is usually ineffective.
Psychosexual problems
Sexual problems are common in diabetes. Overall,
erectile dysfunction occurs in approximately 50%
of men with diabetes (McCulloch et al, 1980).
Transient erectile dysfunction may be a problem at
times of poor glycaemic control, and retrograde
 APT(1998),vol.4,p.l64
ejaculation and ejaculatory failure may also occur.
In women, orgasmic dysfunction and reduced
vaginal lubrication have been reported (Kolodny,
1971; Jensen, 1981).
The sexual problems encountered in diabetes
may initially be the result of neurological and
vascular complications, but frequently a mixture of
physical and psychological factors are important.
For example, a young man with diabetes may notice
a slight reduction in the strength of his erection due
to early microvascular changes, but this may be
exacerbated by anxiety and lead to presentation
with impotence. It is important to try to establish
the extent to which physical and psychological
factors are contributing to the problem, but a
considerable degree of uncertainty may need to be
tolerated regarding the relative importance of the
various aetiological factors (Hawton, 1985). The
situation will usually become clearer as psychosexual
therapy proceeds. Alternatively, there are an
increasing number of options for physical treatment,
especially of erectile dysfunction, including oral
yohimbine and newer agents, intracavernosal
injection of prostaglandin E, and penile surgery
(still considered a last resort).
Other psychiatric disorders
Several other psychiatric disorders occur commonly
in association with diabetes. These include:
(a) phobias - especially related to needles and
injections;
(b) obsessive-compulsive disorder - which may
involve blood glucose monitoring and other
attention to detail which is particularly
necessary in Type I diabetes;
(c) alcohol and drug dependence;
(d) panic disorder (note: symptoms of hypo-
glycaemia may precipitate or mimic a panic
episode); and
(e) schizophrenia.
There is little research into the treatment of these
disorders in people with diabetes, but there is no
reason to believe that the management which is
appropriate and effective in the physically well will
be any less so in patients who also have diabetes. It
is important, however, to consider the possible
effects of the psychiatric disorder upon the person's
ability to manage his or her diabetes effectively, and
to monitor their glycaemic control. It is also
important for the mental health team to be aware
of the possible effects of any treatments they use
upon diabetes, and to make management choices
with this in mind. For example, there have been
isolated case reports of hyperglycaemia with both
Trigwell & Peveler
mianserin and high-dose clozapine, and propran-
olol may lead to a prolonged hypoglycaemic
response to insulin (Bazire, 1996).
Role of the psychiatrist
When responding to a request to see a general
hospital patient for assessment, there is a temptation
to screen the person for formal (classifiable) mental
disorder and to offer no further help if the person's
symptoms do not strictly satisfy such criteria. This
narrow 'mental model' is no more helpful than a
narrow 'medical model' would be in such patients.
It is not an adequate response to the original request
for an opinion, which will invariably have been
asking two main questions: are psychological
factors important in the presentation of this case;
and would a psychiatric intervention be helpful?
The psychiatrist needs to employ a broad-based
biopsychosocial model in carrying out the assess
ment and, if the answers to the two questions are
'yes', to take a pragmatic, problem-based approach
to helping with management. Both psychological
and physical elements may be important in
management, along with continued close liaison
with the medical team. It cannot be over-stated that
levels of psychological distress which might be
Box 3. Key points
People with diabetes suffer from a spectrum
of psychological problems, ranging from
mild difficulties in adjusting to diabetes to
'full-blown' psychiatric disorders.
Good diabetes management makes extreme
demands on patients'behaviour.
Disorders which may be regarded as mild in
the physically well may assume greater
significance when they occur together with
diabetes, because of their impact on self-
care and the consequent outcome of the
diabetes.
Psychiatrists need to avoid the pitfall of not
treating 'understandable' psychological
problems.
Modifications to standardtreatmentapproaches
may be required when diabetes is present.
Close collaboration between the psychiatric
and medical teams is necessary in dealing
with patients who suffer from both
diabetes and a psychiatric disorder.
 Psychiatrie aspects of diabetes
considered subclinical in the physically well must
be actively addressed in conditions such as diabetes
in view of their effects upon self-care and, con
sequently, upon the future physical and psycho
logical well-being of the patient. It is very important
for the psychiatrist to identify and deal with any
diagnosable psychiatric disorder but, in addition,
he or she must be able to offer advice and support
to the medical team regarding psychological
problems of a lesser degree.
References
Bazire, S. (1996)PsycliotropicDrug Directory.Wiltshire: MarkAllen.
Diabetes Control and Complications Research Group (1993)The
effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent
diabetes mellitus. Neu>EnglandJournal ofMedicine,329,977-986.
Fakhri, O., Fadhli, A. A. & el Rawi, R. M. (1980) Effect of electro-
convulsive therapy on diabetes mellitus. Lancet,ii, 775-777.
Fairburn, C. G., Peveler, R. C, Davies, B.A., et al (1991) Eating
disorders in young adults with insulin dependent diabetes: a
controlled study. British MedicalJournal, 303,17-20.
Finestone, D. H. & Weiner, R. D. (1984) Effects of ECT on diabetes
mellitus. Acta PsychiatricaScandinavia, 70,321-326.
Fris, R. & Nanjundapper, G. (1986) Diabetes, depression and
employment status. SocialSciencesand Medicine,23,471—475.
Geringer, E. S. (1990)Affective disorders and diabetes mellitus. In
Neuropsychological and Behavioural Aspects of Diabetes (ed. C. S.
Holmes). New York:Springer-Verlag.
Gréer, S., Morris, T. & Pettingdale, K. W. (1979) Psychological
response to breast cancer: effect on outcome. Lancet,ii, 785-787.
Harris, E.C. & Barraclough, B.M. (1994)Suicide as an outcome for
medical disorders. Medicine,73,281-296.
Hawton, K. (1985) Sex Therapy:A Practical Guide. Oxford: Oxford
Medical Publications.
Haynes, R. B.,Taylor, D. W. & Sackett, D. L. (1979) Compliancein
Healthcare.Baltimore, MD: Johns Hopkins Press.
Jensen, S. B. (1981) Diabetic sexual dysfunction: a comparative
study of 160insulin treated diabetic men and women and an age
matched control. ArchivesofSexualBehaviour,10,493-504.
Kaplan, S. M., Mass, J. W., Pixley, J. M., et al (1960) Use of
imipramine in diabetes. Journal of the American Medical
Association, 174,511-517.
Kolodny, R. C. (1971) Sexual dysfunction in diabetic females.
Diabetes,20,557-559.
Lustman, P J.,Griffith, L.S.,Gavard, J.A., et al (1992)Depression in
adults with diabetes. DiabetesCare, 15,1631-1639.
McCulloch, D. K., Campbell, I. W., Wu, F. C., et al (1980) The
prevalence of diabetic impotence. Diabetologia,18,279-283.
Maguire, P.& Haddad, P.(1996)Psychological reactions to physical
illness. In Seminars in Liaison Psychiatry (eds E. Guthrie & F.
Creed), pp. 157-191. London: Gaskell.
Maudsley, H. (1899) The Pathology of Mind (3rd edn). New York:
Appleton.
Mayou, R., Peveler, R., Davies, B.,etal (1991)Psychiatric morbidity
in young adults with insulin-dependent diabetes mellitus.
PsychologicalMedicine,21,639-645.
Normand, P.S. &Jenike, M.A. (1984)Lowered insulin requirements
after ECT.Psychosomatic», 25,418-419.
Orr, D. P.,Golden, M. P.,Myers, G.,et al (1983) Characteristics of
adolescents with poorly-controlled diabetes referred to a tertiary
care centre. DiabetesCare,6,170-175.
Peveler, R.C., Fairburn, C. G., Boiler,l,etal (1992)Eating disorders
in adolescents with insulin-dependent diabetes mellitus. Diabetes
Care,10,1356-1360.
— & — (1992)The treatment of bulimia nervosa in patients with
diabetes mellitus. International Journal of Eating Disorders, 11,
45-53.
APT (1998), vol. 4, p. 165
— & Tooke, J. E. (1995)The young diabetic. In Psychiatric Aspects
of PhysicalDisease(eds A. House, R. Mayou & C. Mallinson), pp.
9-16. London: Royal College of Physicians and Royal College of
Psychiatrists.
Popkin, M. K.,Callies,A. L.& Mackenzie, T.B.(1985)The outcome
of antidepressant use in the medically ill. Archives of General
Psyc/!Min/,42,1160-1163.
Rodgers, B.'&Mann, S. A. (1986)The reliability and validity of PSE
assessments by lay interviewers: a national population survey.
PsychologicalMedicine,16,689-700.
Sarán,A. S. (1982)Antidiabetic effects of lithium. Journal ofClinical
Psychiatry,43,383-384.
SteeCJ. M.,Young, R.J., Lloyd, G. C.,etal (1987)Clinically apparent
eating disorders in young diabetic women: associations with
painful neuropathy and other complications. British Medical
Journal,294,859-862.
Tattersall, R. B. (1985) Brittle diabetes. British MedicalJournal, 291,
555-557.
— & Walford, S. (1985) Brittle diabetes in response to life stress:
"Cheating and Manipulation". In Brittle Diabetes (ed. J. C.
Pickup), pp. 76-102. Oxford: Blackwell Scientific.
Trigwell, P.J., Grant, P.J. & House, A. O. (1997) Motivation and
glycaemic control in diabetes mellitus. Journal of Psychosomatic
Research,43,307-315.
True, B. L., Perry, P. J. & Burns, E. A. (1987) Profound
hypoglycaemia with the addition of a tricyclic antidepressant
to maintenance sulfonylurea therapy. American Journal of
Psychiatry, 144,1220-1221.
Turkington, R. (1980) Depression masquerading as diabetic
neuropathy.
1147-1150. ' Journal of the American Medical Association, 243,
Weyerer, S., Hewer, W., Pfeifer-Kurda, M.,t'Ã-¡¡/(1989)Psychiatric
disorders and diabetes: results from a community study. Journal
of PsychosomaticResearch,33,633-640.
Wilkinson, G., Borsey, D. Q., Leslie, P., et al (1988) Psychiatric
morbidity and social problems in patients with insulin-
dependent diabetes mellitus. British Journal of Psycliiatry, 153,
38-43.
Williams, G., Gill, G. & Pickup,]. (1991) "Brittle" diabetes. British
MedicalJournal,303,714.
Wrigley,M. & Mayou, R. (1991) Psychosocial factors and admission
for poor glycaemic control. Journal of Psychosomatic Research,
35,335-344.
Wulsin, L. R., Jacobson,A. M. & Rand, L. I. (1987) Psychosocial
aspects of diabetic retinopathy. DiabetesCare,10,367-373.
Multiple choice questions
1. Major depressive disorder in a person with Type
I diabetes:
a should not be treated with antidepressant
medication if it is an understandable reaction
to the diabetes
b does not respond to electroconvulsive therapy
c may present with worsening glycaemic
control
d should generally be treated with fluoxetine as
the first-choice antidepressant
e may lead to proliferative retinopathy.
2. Possible complications of diabetes mellitus
include:
a chronic neuropathic pain
b blindness
c obsessive-compulsive disorder
 APT(1998), vol. 4, p.l66 Trigwcfl & Peveler

d renal failure 6. In Type I diabetes:

e retrograde ejaculation. a extreme and frequent fluctuations in
glycaemic control are the result of abnormal
3. Hypoglycaemia: insulin absorption
a only occurs in patients with Type I diabetes b sexual dysfunction is almost always caused
b can lead to permanent brain damage entirely by organic factors
c may mimic a panic attack c the risk of later medical complications is
d occurs least frequently in those with 'brittle' increased in those with mild forms of
diabetes psychiatric disorder
e may be precipitated by SSRIs. d erectile dysfunction may improve with
improved glycaemic control
4. Research has shown people with diabetes to be e denial is a particularly effective coping style.
at increased risk of:
a depression
b completed suicide
c cardiovascular disease
d severe anorexia nervosa
e sexual dysfunction.

5 The following may be signs of psychiatric MCQan weI

disorder in diabetes: 1 2 3 4 5 6
a reduced frequency of blood testing aF a T a F a T a T a F
b increased alcohol intake bF b T b T b F b T b F
c increased frequency of blood testing cT c T c T c T c T c T
d reduced clinic attendance dF d T d F d F d T d T
e admission to hospital with hyperglycaemic eT e T e T e T e T e F
ketoacidosis.